Pediatric Neurosurgery, Medicaid, and the Affordable Care Act

hslammuhSandi Lam, MD, MBA (left)
Associate Professor
Division of Pediatric Neurosurgery/Department of Neurosurgery
Texas Children’s Hospital/Baylor College of Medicine
Baylor Center for Ethics and Health Policy

Carrie R. Muh, MD, MS (right)
Assistant Professor of Neurosurgery and Pediatrics
Duke University Medical Center
Duke Institute for Brain Sciences

Pediatric Neurosurgery and the Health of Children  

pediatric-neurosurgeryOnce again, policymakers are debating ways to reform the U.S. health care delivery system, and over the coming weeks, Congress and the Trump Administration will be considering legislative and executive actions to modify the Affordable Care Act (ACA). For pediatric neurosurgeons, subspecialty surgical care is directly linked to pediatric health care delivery. High-quality, safe neurosurgical care for children, requires dedicated infrastructure as well as the collaborative services of pediatric medical/surgical specialties. The well-being of the entire family is critical, as over 98 percent of pediatric discharges are to home.

Health coverage-related disparities in access and clinical outcomes are well-described in pediatric surgical subspecialties. The optimal health care system is the subject of discourse, but all can agree that we must provide care for our littlest and most vulnerable patients. While the Medicaid program has recognized shortcomings (including low reimbursements, high administrative burden and extended payment wait times), the reality is that Medicaid provides needed access to health care for lower-income families and children, especially children with special health care needs.

Understanding the potential implications of repealing and replacing the ACA and restructuring Medicaid — which accounts for 17 percent of national health expenditures and serves children and families, people with disabilities, and individuals in long-term care — needs to be part of this discussion.

Why Does Medicaid Matter to Children?

Medicaid is jointly funded by states and the federal government. It covers 74 million people, including 30 million children. Medicaid provides insurance coverage for just a little less than employer-based plans (48 percent of children in the U.S. are covered by employer-based insurance, while 39 percent are covered by Medicaid.) In some states, over 50 percent of the pediatric population is covered by Medicaid. (For a Medicaid pocket primer, click here.)

In addition to providing coverage for low-income families, Medicaid and the Children’s Health Insurance Plan (CHIP) provide coverage or fill coverage gaps for children with complex medical conditions. The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit in Medicaid provides access to preventive services and other essential care, and 76.5 percent of pediatricians accept new Medicaid patients. An estimated 1 million children are covered in the marketplace among the 20 million Americans who have gained health insurance coverage with the ACA. Many private plans in the marketplaces offer essential health benefits similar to EPSDT, though this may no longer be the case if health reform legislation under consideration becomes law.

Medicaid’s expansion under ACA was made optional by the Supreme Court’s landmark ACA decision. While targeted at the higher rate of uninsured adults, the ACA built upon Medicaid and CHIP programs, and a record number of America’s children (95.2 percent) now have health care coverage. Many children became insured as a consequence of increased parental awareness with the ACA, which is also referred to as the “welcome mat” effect. The Maintenance of Effort (MOE) provision requires states to maintain their current eligibility levels for children’s coverage in Medicaid and CHIP until 2019. The rate of uninsured varies significantly between states. States with the highest rates of uninsured include Alaska, Florida, Georgia, Oklahoma, and Texas; even in these states, the total percent of uninsured has decreased since 2013. The South is home to 38 percent of US children, yet account for 50 percent of the country’s uninsured children. One in five uninsured children now lives in Texas. While children had increased enrollments across age groups, racial categories, and income ranges, disparities persist. For example, Latino children are disproportionately uninsured. Children living just over the poverty line (100-200 percent of Federal Poverty Level) have the highest rates of uninsurance (6.8 percent).

Medicaid Recipients Rely on Children’s Hospitals

The practice setting of many pediatric neurosurgeons is that of children’s hospitals. These hospitals are at the core of health care delivery for the pediatric population, with teams of pediatric specialists often not available in other settings. Children’s hospitals constitute less than 5 percent of hospitals in the U.S., yet account for 35 percent of hospital days for children on Medicaid and 53 percent of hospital days for children with complex medical conditions, such as neurosurgical conditions.

Because of the small number of children’s specialty centers, each institution serves a broader geographic area than most adult hospitals. For families, particularly those with medically complex children, this geographic dispersion may mean traveling long distances or across state lines to meet specialized health care needs. For children’s specialists, this requires coordinating with multiple state Medicaid programs that reimburse at most up to 80 percent of the cost of care including Disproportionate Share Hospital (DSH) payments.

Recent policy efforts for Medicaid reform aim to cut costs, promote efficiency, and improve care for children. In the 114th Congress, the bipartisan Advancing Care for Exceptional Kids Act, or ACE Kids Act, (S.298/H.R. 546), which the AANS and CNS endorsed, was introduced. The ACE Kids Act creates a state opt-in for a national framework to coordinate care across state lines for children with medical complexity in Medicaid to improve quality while reducing costs.

Risks of Restructuring Medicaid Financing

Medicaid constitutes over 50 percent of all federal funding to states. Proposals for restructuring Medicaid include block grants and per capita caps limiting federal contributions. Restructuring Medicaid financing may result in a shift of costs and risk to states, potentially removing guarantees of coverage, and increasing the number of uninsured children. It would also put pressure on other state-funded programs (such as education, child care and welfare), which could weaken the ability of states to respond to public health crises and economic downturns. Such limitations further strain a safety net that is already stretched. Barriers for children to access preventive, primary and specialty care can increase health care costs and utilization in the long run. (For more information on block grants and per capita caps, click here.)

Role for Neurosurgery:  Be a Part of the Solution

Children with neurological complex chronic conditions require a disproportionately large amount of health care resources (Figure 1). These high-resource utilization groups can be targeted for innovation in care delivery models.

Figure 1 shows resource utilization of children with neurologic disease

Figure 1 shows resource utilization of children with neurologic disease

Innovative solutions should aim to improve care, increase efficiency, achieve savings and bend the cost curve with an ever-better Medicaid program. Medicaid is a lifeline providing coverage for a significant portion of children in the U.S. In the limited scope of this piece, directions for the future are framed within the current system. Barring the creation of an entirely new health care system, it is not feasible to reduce financial support to a program and expect it to outperform. We can, however, learn from best practices and high performers. A framework that supports the sharing of national data, clinical standards, and quality measures designed for children, could accelerate implementation of effective and efficient care within Medicaid. The bipartisan ACE Kids Act is certainly a step in the right direction.

In light of the current national debate, this is a critical time for neurosurgeons to take an active role in reshaping health care policy. With our experience in the treatment of complex patients, incorporation of technology, and leadership of surgical/medical teams, neurosurgeons are uniquely equipped to help address much-needed innovation in health care delivery. Let’s rise to the many challenges in health care and be part of the solution.

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Neurosurgery Resident Duty Hours and the Learning and Working Environment

bobGuest post from Robert E. Harbaugh, MD, FAANS, FACS, FAHA
Past President, American Association of Neurological Surgeons
Past President, Society of Neurological Surgeons
Director, Institute of the Neurosciences
Distinguished Professor and Chair, Department of Neurosurgery
Professor, Department of Engineering Science & Mechanics
The Pennsylvania State University
Milton S. Hershey Medical Center
Hershey, PA

After thirteen years of duty hours restrictions, it was important for the Accreditation Council for Graduate Medical Education (ACGME) to assess the impact those regulations had had on patient safety and resident training. So last year, on March 16-17, 2016, the ACGME convened a congress on resident duty hours in Chicago. It was evident to everyone who attended that the ACGME had made a real commitment to hear all the evidence and do what was best for our residents, our patients and our profession. I was impressed by the thoughtful analysis presented at that meeting by many medical and surgical disciplines. Almost universally, those physicians with the most experience in training resident physicians felt that the rigid shifts of the present system had had many negative consequences and asked the ACGME to ease work hour restrictions. Following the congress, the ACGME analyzed and discussed the voluminous data and made recommendations to improve the resident learning environment. These final recommendations, which were announced on March 10, 2017, include a modest increase in work hours for first-year residents and increased flexibility for all residents regarding their “shifts.”

acgme2Throughout this process, there was a commitment from the ACGME to collect and analyze the data rather than try to make the data fit a predetermined outcome. The response to the ACGME recommendations has, however, taken a different course. The proposal for modest changes in work hour restrictions has been met with invective from the usual suspects. Once again we hear the anecdotes of brutally mistreated residents putting their own and their patients’ lives at risk, the question of “Do you want an exhausted doctor taking care of you?” and the mostly meaningless comparisons to other jobs. What we haven’t seen is data to support the tantrums.

An ever-increasing volume of data, including data from prospective randomized trials, suggests that we accepted a false premise that restricting duty hours would improve patient safety and resident training. It is becoming increasingly clear that we have not enhanced the safety of today’s patients. As worrisome is the fact that we are also sacrificing the safety of future patients by adversely affecting resident training. Over the last decade, studies and surveys have documented the following negative consequences resulting from the current duty hour restrictions:

  • A reduction in the total hours of surgical experience;
  • The use of midlevel practitioners for educationally valuable activities;
  • Decreased time spent in outpatient clinics;
  • Fewer elective operations;
  • Compromises in the continuity of care; and
  • Reduced research and conference time.

Perhaps most important, current duty hour rules foster a shift-work mentality with its attendant loss of personal commitment to the patient. The current system forces our residents to choose between adherence to regulations requiring them to end their shift or their commitment to patients who would still benefit from their care. Neurosurgery is a demanding technical specialty, but we do much more than perform procedures. We care for our patients in the clinic, the emergency room, the operating room, the recovery room, the intensive care unit and the hospital wards. We are specialists in the care of patients with neurological disease, not merely technicians who have mastered a motor skill. We are professionals, not shift-workers. We have always taken care of our patients whenever they need us, for as long as they need us and we should continue to train our residents to put their patients’ interests first.

acgmeAdhering to an arbitrary shift schedule has erected significant barriers to neurosurgical training. Neurosurgical learning episodes — from initial contact with the patient, through diagnostic evaluation, surgical treatment and immediate postoperative care — encompass many hours. To obtain the greatest educational value from these learning episodes, a resident must be present throughout this sequence of events. When these episodes cross the shift boundaries set up by work hour restrictions, as is often the case, our residents are forced to decide between doing what is best for their patients and their education or following the rules that tell them that their shift is over and they must punch the clock.

Fatigue is a fact of life for neurosurgeons. Maximizing patient safety and resident education requires attention to supervision and fatigue management, not designated shifts. Supervision will vary according to the level of training, with junior residents requiring more immediate supervision than senior residents who are assuming a greater degree of autonomy and responsibility for patient care. The last years of resident training should be a transition to practice during which residents develop the time management, clinical and operative skills to become an independent neurosurgical practitioner. Allowing a more flexible schedule within the current 80-88 hour work-week and eliminating the work hour restrictions for 6th and 7th-year residents would help our trainees internalize the importance of continuity of care, take personal responsibility for their patients, avoid the moral dilemmas of the present system and enhance professionalism.

The modest changes adopted by the ACGME, which increase the work hours for first-year residents and give all residents a bit more flexibility regarding their “shifts” is a small, but critical step in the right direction.

Posted in GME, Guest Post, Health, MedEd | Tagged , , , , , , , , , |

Neurosurgery over NFL: Match Day 2017

myronMyron L. Rolle
Medical student, Florida State University 

One of the more anticipatory moments of my life was the 2010 National Football League Draft. I sat on the couch in my home alongside my parents and brothers. There were camera crews from the NFL Network and ESPN crowded inside our small living room. My phone was ringing off the hook with nervous friends providing their brand of support. My agent reassured me that teams were still interested in me. Twitter even had me as a trending topic: Where will Myron Rolle, the Rhodes Scholar and Florida State All-American Safety, get drafted? It was a good question. One for which I had no answer. Then, alas, on the third day of that draft, I received a call from a 615 area code. It was Jeff Fisher, Head Coach of the Tennessee Titans. He asked me if I was ready to join the squad. I exclaimed, “Absolutely, sir!” It was a dream come true to be drafted and play professional football. I had been playing the sport since I was six-years-old and I had become the number one ranked high school player in the U.S. My cousins, Samari and Antrel Rolle, had extensive careers in the NFL. My daddy founded the Commonwealth American Football League back home in our country of the Bahamas. To get drafted that special day was the reward for years of hard work. Unequivocally.

Picture1Needless to say, football has been a part of my journey for a long time. But you see, there has been a parallel path that has traveled right next to football. This path will take me even farther, give me an even greater purpose and provide a way to help people and communities significantly. This path is neurosurgery.

My oldest brother Marchant gave me a book in the 5th grade called, “Gifted Hands by pediatric neurosurgeon Benjamin S. Carson, Sr., MD. This book inspired me because I saw a hero in a man that looked like me and had a similar family story as me. Dr. Carson planted the seed of neurosurgery in my mind, but it truly blossomed after I spent two months as a first assist with another pediatric neurosurgeon named Phillip B. Storm, MD, FAANS at Children’s Hospital of Philadelphia. Dr. Storm and I did clival chordoma resections, moyamoya cases, ventriculoperitoneal shunts and spinal deformities. Dr. Storm had a sincere manner with his patients, and they often returned to him 10 years later thanking him for his care. I would go home from the operating room every day feeling energized like I had made 14 tackles, two interceptions and scooped up a fumble for a game-winning touchdown. That is how pumped up I was, and that was the moment I knew this calling was truly mine.

So now it is 2017 and another anticipatory moment is one week away — Match Day! Similar to the NFL draft, I will be nervous, excited, sitting alongside my family and receiving calls from supportive friends. The camera crews probably won’t make it, but that is just fine. Matching into neurosurgery will be another dream come true. And when the chairman of my destined program calls and asks me if I am ready to join the department, I will exclaim — with the same vigor I did seven years ago — “Absolutely, sir!”

Editor’s Note: To read more about Myron’s journey to neurosurgery click here and here. On March 17, 2017, Myron matched to Massachusetts General Hospital. We wish him all the best during his neurosurgical residency!


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